Though tuberculous granulomata of the pituitary or its stalk are often included in the lists of causes of hypopituitarism, most of the cases have in fact been diagnosed only at necropsy. Chronic clinical hypopituitarism due to proved tuberculosis has rarely been reported. CASE REPORTThe patient had developed tuberculosis of the lungs, spine, and meninges when she was aged 6. Streptomycin therapy was given for two years and she was discharged from hospital after a further tear. The menarche occurred at age 10; the periods lasted for only four cycles, though lower abdominal pain at monthly intervals continued for a further six months. Thereafter there was no cyclical pain or bleeding.At age 20 she was investigated elsewhere for amenorrhoea; she was short of stature (145 cm.) and no signs of active tuberculosis were obtained. A vaginal smear showed no evidence of oestrogenic activity. Curettage was attempted but no endometrium could be X-ray fihn of skull to show suprasellar calcification, presumably in the meninges.obtained from the small uterus. Cyclical oestrogen therapy was started and resulted in enlargement of the breasts and uterus and withdrawal bleedings. On discontinuing the therapy no spontaneous periods occurred.At age 27 she developed a sore throat, pyrexia, and hypotension (B.P. 90/60) and rapidly lapsed into a stuporous condition. No evidence of raised intracranial pressure was found. In view of the history and the finding of very scanty pubic and axillary hair she was treated with intramuscular hydrocortisone as well as ampicillin. A rapid recovery ensued and therapy was temporarily withheld while laboratory tests were performed.Investigations.-The plasma cortisol was 3.4 and 2.4 ,ug./100 ml. at 10 a.m. on two occasions. The urinary daily excretion of 17-hydroxycorticosteroids and 17-oxosteroids was 2.3 and 1.5 mg. respectively. On the day 3 g. of metyrapone was administered orally the 17-hydroxycorticosteroid excretion was 2.8 mg. and on the following day it was 2.0 mg. Injection of A.C.T.H. gel (20 units b.d. for three days) increased the 17-hydroxycorticosteroid excretion to 20.5 mg./24 hours. The serum protein-bound iodine was 2.9 ,ug./lO ml. and the serum thyroxine 4.3 pg./100 ml. The four-hour 182I uptake was 11.0%. This was increased to 29.2% after 10 units of thyroid stimulating hormone. The urinary excretion of gonadotrophins was less than 3 i.u./24 hours. The total urinary oestrogen excretion was 16 jug./24 hours. There was no polyuria and serum electrolytes were normal. X-ray examination of the skull showed suprasellar calcification (see Fig.).After treatment with cortisone and thyroxine the patient felt muchmore alert and active and less cold-sensitive. COMMENTThe laboratory investigations confirm the diagnosis of hypopituitarism. The lack of evidence suggestive of a spaceoccupying lesion and the presence of suprasellar calcification make it almost certain that the hypopituitarism followed the tuberculous meningitis.Tuberculosis has been reported to affect both the parenchyma of the ante...

This article is an adaptation of the winning essay in the preregistration section of the National Board for Northern Ireland Research Awards 1996. The authors conducted a literature review of handwashing after discovering during clinical placements that, despite being well documented, handwashing is still not performed as necessary. The aim of handwashing is to remove transient microorganisms and prevent their transfer to susceptible patients. Inadequate training, lack of resources, chapped hands and poor reinforcement were identified by nurses as factors that accounted for poor handwashing. The Code of Professional Conduct states that 'the professional has a duty to promote and safeguard the interests of clients.' It is only a matter of time before major litigation occurs because of poor handwashing practice. It is concluded that all staff (trained and untrained) require regular educational updating to sustain good handwashing practices. Managers are responsible for ensuring the provision of adequate facilities and supplies of handwashing agents for all nurses in all clinical settings.

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